BackgroundFoot musculoskeletal deficits are seldom addressed by preventive medicine despite their high prevalence in patients with diabetic polyneuropathy.AIM: To investigate the effects of strengthening, stretching, and functional training on foot rollover process during gait.MethodsA two-arm parallel-group randomized controlled trial with a blinded assessor was designed. Fifty-five patients diagnosed with diabetic polyneuropathy, 45 to 65 years-old were recruited. Exercises for foot-ankle and gait training were administered twice a week, for 12 weeks, to 26 patients assigned to the intervention group, while 29 patients assigned to control group received recommended standard medical care: pharmacological treatment for diabetes and foot care instructions. Both groups were assessed after 12 weeks, and the intervention group at follow-up (24 weeks). Primary outcomes involved foot rollover changes during gait, including peak pressure (PP). Secondary outcomes involved time-to-peak pressure (TPP) and pressure–time integral (PTI) in six foot-areas, mean center of pressure (COP) velocity, ankle kinematics and kinetics in the sagittal plane, intrinsic and extrinsic muscle function, and functional tests of foot and ankle.ResultsEven though the intervention group primary outcome (PP) showed a not statistically significant change under the six foot areas, intention-to-treat comparisons yielded softening of heel strike (delayed heel TPP, p=.03), better eccentric control of forefoot contact (decrease in ankle extensor moment, p<.01; increase in function of ankle dorsiflexion, p<.05), earlier lateral forefoot contact with respect to medial forefoot (TPP anticipation, p<.01), and increased participation of hallux (increased PP and PTI, p=.03) and toes (increase in PTI, medium effect size). A slower COP mean velocity (p=.05), and an increase in overall foot and ankle function (p<.05) were also observed. In most cases, the values returned to baseline after the follow-up (p<.05).ConclusionsIntervention discreetly changed foot rollover towards a more physiological process, supported by improved plantar pressure distribution and better functional condition of the foot ankle complex. Continuous monitoring of the foot status and patient education are necessary, and can contribute to preserving the integrity of foot muscles and joints impaired by polyneuropathy.Trial registrationClinicalTrials.gov Identifier: NCT01207284, registered in 20th September 2010.

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We conducted a randomized controlled multicentre trial to investigate the feasibility of a telerehabilitation intervention for arm/hand function (the Home Care Activity Desk [HCAD] training) in a home setting. Usual care was compared to HCAD training. The hypothesis was that the clinical outcomes of the HCAD intervention would be at least the same as those measured after a period of usual care for patients with stroke, traumatic brain injury (TBI) and multiple sclerosis (MS) with respect to their arm/hand function. Eighty-one patients with affected arm/hand function resulting from either stroke, MS or TBI were recruited in Italy, Spain and Belgium; 11 were lost during follow-up (14%). The outcome measures were the Action Research Arm Test (ARAT) and the Nine Hole Peg Test (NHPT). There were no significant differences between the two groups on the outcome measures (ARAT and NHPT); in both groups, patients maintained or even improved their arm/hand function. The HCAD training was found to be as feasible as usual care in terms of clinical outcomes, and both therapists and patients were satisfied with the HCAD intervention. A telerehabilitation intervention using HCAD may increase the efficiency of care.

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OBJECTIVE -Diabetic neuropathic patients show a peculiar loading pattern of the foot, which led us to hypothesize that a substantial modification exists in their deambulatory strategy. The aim of the present study was to support this hypothesis by quantifying the changes of the loading patterns and by monitoring the excursion of center of pressure (COP) during gait. RESEARCH DESIGN AND METHODS-A total of 21 healthy volunteers (C) and 61 diabetic patients were evaluated: 27 diabetic subjects without neuropathy (D), 19 with neuropathy (DN), and 15 with previous neuropathic ulcer (DPU). A piezo-dynamometric platform was used to record the foot-to-floor interaction by measuring loading time and the instantaneous COP position during the stance phase of gait.RESULTS -Loading time was significantly longer in neuropathic patients than in control subjects (DPU: 816.8 Ϯ 150 ms; DN: 828.6 Ϯ 152 ms; D: 766.5 Ϯ 89.9 ms; C: 723.7 Ϯ 65.7 ms; P Ͻ 0.05). COP excursion along the medio-lateral axis of the foot clearly decreased from C to DPU groups (C: 6.41 Ϯ 0.1 cm; D: 4.88 Ϯ 0.2 cm; DN: 4.57 Ϯ 0.1 cm; DPU: 3.36 Ϯ 0.1 cm; P Ͻ 0.05) as well as COP excursion along the longitudinal axis for the DPU group only (C: 26.6 Ϯ 1 cm; D: 26.9 Ϯ 1 cm; DN: 27.2 Ϯ 1 cm; DPU: 24.2 Ϯ 1 cm; P Ͻ 0.05). COP integrals were significantly reduced for all pathological classes (DPU: 14.2 Ϯ 8 cm 2 ; DN: 25.8 Ϯ 6 cm 2 ; D: 27.7 Ϯ 3 cm 2 ; C: 38.6 Ϯ 6 cm 2 ; P Ͻ 0.05).CONCLUSIONS -The accurate quantification of loading patterns and of COP excursions and integrals highlights changes of foot-to-floor interaction in diabetic neuropathic patients. The decreased medio-lateral and longitudinal COP excursions and corresponding changes of loading times and patterns support our hypothesis that a change in the walking strategy of diabetic patients with peripheral neuropathy does occur. Diabetes Care 25:1451-1457, 2002A bnormal plantar pressures are considered the main cause of neuropathic foot ulceration (1-5). However, high pressures are only the last ring of a chain to which several factors contribute, including peripheral neuropathy and limited joint mobility. It is worth emphasizing that those factors may influence not only the foot loading, but, more widely, the whole performance of the lower limb during gait.A few authors have suggested that patients with peripheral neuropathy develop a change in their walking strategy, shifting from an ankle to a hip strategy (6,7). In a recent article, our group also hypothesized this kind of change by analyzing the foot loading pattern (8). The aim of the present work was to further support this hypothesis by using a different parameter, namely the evolution of the center of pressure (COP) that is the point of application of the ground reaction force (GRF). COP records the succession of instantaneous positions during the entire period of contact between foot and floor and is plotted as a sequence of points on the ground plane. It takes into account the displacement of load throughout the foot during the stance phase of a wal...

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Increased thickness of Achilles tendon and plantar fascia, more evident in the presence of neuropathy, may contribute to an overall increase of tensile force and to the occurrence of an early Windlass mechanism, maintained throughout the whole gait cycle. This might play a significant role in the overall alteration of the biomechanics of the foot-ankle complex.

OBJECTIVES -Secondary to peripheral neuropathy, plantar hyperpressure is a proven risk factor for foot ulceration. But limited joint mobility (LJM) and soft tissue abnormalities may also contribute. The aim of this study was to evaluate the relationships among thickness of plantar fascia, mobility of the metatarso-phalangeal joint, and forces expressed under the metatarsal heads.RESEARCH DESIGN AND METHODS -We evaluated 61 diabetic patients: 27 without neuropathy (D group), 19 with neuropathy (DN group), and 15 with previous neuropathic foot ulceration (DNPU group). We also examined 21 control subjects (C). Ultrasound evaluation was performed with a high resolution 8-to 10-MHz linear array (Toshiba Tosbee SSA 240). The foot loading pattern was evaluated with a piezo-dynamometric platform. First metatarsophalangeal joint mobility was assessed with a mechanic goniometer.RESULTS -Diabetic patients presented increased thickness of plantar fascia (D 2.9 Ϯ 1.2 mm, DN 3.0 Ϯ 0.8 mm, DNPU 3.1 Ϯ 1.0 mm, and C 2.0 Ϯ 0.5.mm; P Ͻ 0.05), and significantly reduced motion range at the metatarso-phalangeal joint (D 54.0 Ϯ 29.4°, DN 54.9 Ϯ 17.2°, DNPU 46.8 Ϯ 20.7°, and C 100.0 Ϯ 10.0°; P Ͻ 0.05). The evaluation of foot-floor interaction under the metatarsal heads showed increased vertical forces in DN and DNPU and increased medio-lateral forces in DNPU. An inverse correlation was found between the thickness of plantar fascia and metatarso-phalangeal joint mobility (r ϭ Ϫ0.53). The thickness of plantar fascia was directly correlated with vertical forces under the metatarsal heads (r ϭ 0.52).CONCLUSIONS -In diabetic patients, soft tissue involvement may contribute to the increase of vertical forces under the metatarsal heads. Changes in the structure of plantar fascia may also influence the mobility of the first metatarso-phalangeal joint. Diabetes Care 26:1525-1529, 2003I n diabetic patients, peripheral neuropathy induces foot deformities and changes in the walking pattern that are responsible for the development of areas of high plantar pressure (1-3).Mechanical stress has been recognized to have a central pathogenic role in the onset of diabetic neuropathic ulcers (4). Among the factors that may contribute to increase mechanical stress, limited joint mobility (LJM) of the ankle joint is associated with increased peak forefoot pressures, and therefore with risk of ulceration (5,6). Atrophy and weakness of tibialis anterior and vastus lateralis muscles as well as atrophy of the intrinsic muscles have been recognized to induce important changes in the performance of the ankle movements and in the biomechanical properties of the diabetic neuropathic foot (3). Another well-known cause of increased forefoot pressure is the increased thickness of the Achilles tendon; the efficacy of its surgical lengthening on forefoot pressure release has been investigated and reported in literature, even if the results still show some discrepancies (7,8). Structural changes in the forefoot of diabetic neuropathic patients, in terms of bone and muscle...